Management of Diabetes D - Type 2 Diabetes Mellitus - Part 1 Flashcards
WHat are all the steps involved in the management of type 2 diabetes?
Where/who of the management of Type 2 diabetes - Gain an overview of the structure of care
Why does diabetes need treated? - Gain an overview of some of the challenges in diabetes treatments aims
How do we treat people with type 2 diabetes - Considering holistic care
What medications are used to treat diabetes – part 1 - To gain an understanding of pharmacological agents are used
diabetes is a disorder of the what?
older years and obese
who makes up the diabetes team?
What should a patient should expect from their care?
- Blood glucose levels
- Blood Pressure
- Blood Lipids
- Eyes Screened
- Feet checked
- Kidney function
- Weight
- Smoking Cessation Support
- Individual Care plan
- Education Course
- Emotional and psychological support
how is information shared between healthcare professionals?
SCI Diabetes
where is information avalible to patients?
mydiabetesmyway
Why is it in someones interest to have treatment for diabetes?
relief of primary symptoms
prevention of complications - how else can this be addressed?
preservation of quality of life - balance good effects against side effects
damage minimilisation - avoidace of emergencies
study this flow diagram showing type 2 diabetes
what are symptoms of uncontrolled type 2 diabetes?
frequent urination
increased thirst
blurry vision
feeling drowsy or sleepy
increased hunger - Body cells deprived of glucose even though blood glucose is high so find them selves very hungry
slow or improper healing of cuts and bruises
tingling, pain, or numbness in hands and feet
Prevention of complications - What else needs considered?
mood
smoking
dietary change
statins
blood pressure
physical activity/sedentary behaviour
Legacy Effect of Earlier Glucose Control?
Legacy effect – if managed well earlier on then better down the line
What happens as the percentage of HbA1c increases?
What is the 5 step framework for choosing a glucose lowering drug?
- Set a target HbA1c
- “Take 5” Are there other risk factors that should be treated first?
- Are the current treatments optimised. Max dose? Tolerated? Taken?
- What are the glucose lowering options?
- Remove any that are contraindicated
- Of the remaining what are the pros and cons
- Select the preferred choice.
- Agree a review date and the target HbA1c with the patient
Consider relaxing the target HbA1c level on a case‑by‑case basis - what are some example cases?
People who are older or frail
For adults with type 2 diabetes:
- With reduced life expectancy
- high risk of the consequences of hypoglycaemia- those at increased risk of falling, impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
- intensive management not appropriate- multiple comorbidities
When tpye 2 diabetics have tried hard with lifestyle then the first drug you try is what?
metformin
Why is metformin normally first choice?
- Improves outcomes
- Well tolerated
- Cheap
How does metformin help type 2 diabetes?
Works by improving insulin action
Defect it targets is insulin resistance
works by acting on liver and muscle
what are all the helping affects of metformin?
Biguanide (refers to a group of oral type 2 diabetes drugs that work by preventing the production of glucose in the liver, improving the body’s sensitivity towards insulin and reducing the amount of sugar absorbed by the intestines)
Improves insulin sensitivity:
- Affects glucose production, decrease fatty acid synthesis
- Improves receptor function
- Inhibits gluconeogenic pathways
Half life 6 hours.
what are the advantages of metformin?
Improves cardiovascular outcomes and mortality in obese T2 DM
Efficaceous - Used alone can decrease fasting blood glucose by 22- 26%
Normally well tolerated
Not associated with weight gain
HbA1c by 12 – 17% reduction
Also used in pregnancy now
Cheap
- Metformin 1g bd £2.36
- Metformin MR 1g bd £10.77 (x5)
what are the disadvantages of metformin
GI side effects 20-30 %
Risk of lactic acidosis by inhibiting lactic acid uptake by liver
- Hypoxia
- Renal failure (CI if creat<150)
- Hepatic failure
- Alcohol abuse
Risk vitamin B12 malabsorption
can metformin be used in pregnancy?
yes
If tolerating metformin but not improving glycaemic control enough then what is the next drug used?
use sulfonylurea
The “Gli…ides” – Glimepiride, Gliclazide, Glipizide
How do Sulphonylureas improve type 2 diabetes and where do they act on?
increase insulin release
What is the mechanism of action of sulphonylureas?
Binds to sulfonylurea receptors (SUR-1) on functioning pancreatic beta-cells
Binding closes the linked ATP-sensitive potassium channels
Decreased potassium influx depolarization of the beta-cell membrane
Voltage-dependent calcium channels open and result in an influx of calcium
Translocation and exocytosis of secretory granules of insulin to the cell surface
what are the advantages of sulphonylureas?
Used with metformin
Rapid improvement in control
Rapid improvement if symptomatic
Rapid titration
Cheap
• Gliclazide 160mg bd £3.30 X1.4
• Glimepiride 6mg od £1.72 x0.7
Generally well tolerated
What are the disadvantages of sulphonylureas?
Risk of hypoglycaemia
Weight gain
Caution in renal and hepatic disease
CI in pregnancy and breastfeeding.
SE include:
• Hypersensitivity and photosensitivity reactions
• Blood disorders
What is the next drug that can be used?
Thiazolidinediones
The “…..glitazones” only really Pioglitazone
How do Thiazolidinediones work?
improve insulin action
improve insulin sensitivity
How does Pioglitazone (Thiazolidinediones) work?
selectively stimulates the nuclear receptor peroxisome proliferator-activated receptor gamma (PPAR-gamma) and to a lesser extent PPAR - alpha
modulates the transcription of the insulin-sensitive genes involved in the control of glucose and lipid metabolism in the muscle, adipose tissue, and the liver.
reduces insulin resistance in the liver and peripheral tissues;
increases the expense of insulin-dependent glucose;
decreases withdrawal of glucose from the liver;
reduces quantity of glucose, insulin and glycated haemoglobin in the bloodstream
what are the advantages of Pioglitazone?
Good for people if insulin resistance significant
HbA1c by 0.6-1.3%
Cheap - Pioglitazone 45mg od £1.50 x 0.6
Cardiovascular safety established (Contrast with rosiglitazone)
what are the disadvantages of Pioglitazone?
Increase risk of bladder cancer - Caution in those of increased risk bladder cancer (Age, industry etc)
Fluid retention - CCF
Weight gain
Fractures in females
• Small increased risk
• TZDs affect bone turnover
• Reduced BMD
• Initial report were of increased distal fractures in women
A
Metformin
B
SUs
C
Glitazone
